Provider Demographics
NPI:1841211174
Name:WALDEN-FAIN, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:WALDEN-FAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9517 US HIGHWAY 42 STE 410
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9237
Mailing Address - Country:US
Mailing Address - Phone:502-587-0521
Mailing Address - Fax:502-587-3893
Practice Address - Street 1:9517 US HIGHWAY 42 STE 410
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-9237
Practice Address - Country:US
Practice Address - Phone:502-587-0521
Practice Address - Fax:502-587-3893
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1841211174OtherNPI
KY64012180Medicaid
KY64012180Medicaid
KY00388303Medicare PIN
KY110198605Medicare PIN
KY0078212Medicare PIN
KYCA5762Medicare PIN